Category: Clinical Stones: Equipment (stents, lasers, guidewires, sheaths)
Introduction & Objective :
‘Lost’ ureteric stents are the most common cause of post-operative urological litigation in the UK, with1.2-12.5% of stents forgotten. This ‘never event’ causes morbidity, mortality and significant cost to the NHS.
This project aims for all stents to be accounted for with a culture and practice change, supported by the implementation of a stent register.
A Baseline review of all stents placed across 3 hospitals was performed to identify stents delayed or ‘lost’, identifying any risk factors for this occurrence.
Prospectively all stents were recorded on a stent register (BAUS online or Boston Scientific App) register with warnings providing reminders when stent change or removal was due. This supported education of theatre, surgical and administrative staff to ensure safe follow-up.
Multiple audit cycles with conducted between 2016-18 with further improvements to the service instigated.
Baseline data showed delayed or forgotten stents occurring in 5-8% of cases. Complications included pain, sepsis, need for emergency admission, nephrostomy drainage of an obstructed system and retrograde and/or antegrade removal of encrusted stents.
Initial audit showed register adherence of 55%-76% for retrograde stents and 9-45% for antegrade stents. Emergency stents and those inserted for other specialties were most at-risk. Multiple personnel and system factors were identified and further interventions implemented.
Subsequent audits showed gradual improvement in results up to the point of 100% adherence for both antegrade and retrograde stents and no lost stents.
However one centre then had a drop in stent register use (33%) re-introducing the risk of a delayed or forgotten stent.
Without a zero-tolerance culture, supported by both clinical and non-clinical staff and a functional register, stents will be lost. This causes patient harm and additional cost for health care providers. Stents particularly ‘at risk’ are emergency, antegrade and those inserted for other specialties.
A reliable system and stent register ensures that ureteric stents are followed-up appropriately. An efficient scheduling system is needed to support this culture. Regular audit preserves the highest standards ensuring patient safety is maintained.
The aim remains to create sustained quality improvement, beyond the time span of a particular project or individual’s work. There are numerous barriers to change that require teamwork, communication and persistence to address ensuring that a lost stent is a ‘never event’.
Luke Forster– Specialist Registrar in Urology, Whipps Cross University Hospital, Barts Health NHS Trust, London, England, United Kingdom
Tom Menzies– London, England, United Kingdom
Heather Barnett– London, England, United Kingdom
Srivathsan Ramani– Fellow - Robotic Urooncology, kokilaben dhirubhai ambani hospital, mumbai, Maharashtra, India
Prasad Patki– london, England, United Kingdom
Paula Pal– london, England, United Kingdom
Stuart Graham– Consultant, Department of Urology, Whipps Cross University Hospital, London, London, England, United Kingdom
Specialist Registrar in Urology
Whipps Cross University Hospital, Barts Health NHS Trust
London, England, United Kingdom
Fellow - Robotic Urooncology
kokilaben dhirubhai ambani hospital
mumbai, Maharashtra, India